Table of contents
- Fast facts
- What the 2016 start-of-dialysis data show
- Age patterns at initiation
- Sex and race patterns
- Cause of ESRD and vascular access
- What prevalent hemodialysis access looked like in May 2017
- How the 2005 to 2017 trend changed
- Practical interpretation of the access mix
- Access planning terms to know
Fast facts
Vascular access statistics tell a simple story with complicated consequences: the access used at hemodialysis initiation often differs sharply from the access used later in treatment, and the gap changes by age, sex, race, and cause of kidney disease.
- In 2016, 16.7% of incident ESRD patients started hemodialysis with an AV fistula (2018 USRDS Vascular Access Chapter).
- In 2016, 62.5% started with catheter only (2018 USRDS Vascular Access Chapter).
- By May 2017, 64.5% of prevalent hemodialysis patients were using an AV fistula (2018 USRDS Vascular Access Chapter).
- By May 2017, 18.9% of prevalent hemodialysis patients were using a catheter (2018 USRDS Vascular Access Chapter).
- From 2005 to 2017, AV fistula use at hemodialysis initiation rose from 12.3% to 16.8% (2019 USRDS Executive Summary).
- From 2005 to 2017, AV graft use at hemodialysis initiation decreased from 5% to 3% (2019 USRDS Executive Summary).
- Autogenous AV fistulas require 3 to 6 months to mature, while standard AV grafts can be used after 2 to 4 weeks and early-cannulation grafts within 24 to 72 hours (JAMA 2024 review).
- Maturation failure occurs in 33% to 62% of AV accesses at 6 months and poor patency in 60% to 63% at 2 years (JAMA 2024 review).
- Access-related steal syndrome affects 1% to 8% of patients (JAMA 2024 review).
The most important divide is not just fistula versus graft versus catheter. It is whether the patient starts dialysis with a working permanent access, a maturing access, or a catheter-only setup (2018 USRDS Vascular Access Chapter).
What the 2016 start-of-dialysis data show
The 2016 incident dialysis numbers make clear that catheter dependence was still the dominant starting pattern.
| 2016 hemodialysis start pattern | Share of incident ESRD patients | Source |
|---|---|---|
| AV fistula | 16.7% | 2018 USRDS Vascular Access Chapter |
| AV graft | 3.0% | 2018 USRDS Vascular Access Chapter |
| Catheter with a maturing fistula | 16.1% | 2018 USRDS Vascular Access Chapter |
| Catheter with a maturing graft | 1.6% | 2018 USRDS Vascular Access Chapter |
| Catheter only | 62.5% | 2018 USRDS Vascular Access Chapter |
That table matters because it separates access types that are sometimes blurred together in casual discussion. A catheter-only start is not the same as a catheter used while a fistula matures. The former implies no usable permanent access at initiation, while the latter indicates a temporary bridge toward a planned access route (2018 USRDS Vascular Access Chapter).
The distribution also shows how rare graft starts were in this dataset. Only 3.0% began with an AV graft, and 1.6% began with a catheter plus a maturing graft (2018 USRDS Vascular Access Chapter). By comparison, the fistula pathway was more common, but still far from universal. Even when the fistula category is expanded to include the maturing-fistula bridge group, the incident picture still leaves a large majority in catheter-only territory.
A useful way to read the pattern is this:
- permanent access at start was present, but not the norm.
- temporary catheter use was common enough to shape the whole access landscape.
- the maturing-access pathway was significant, but it did not displace catheter-only starts (2018 USRDS Vascular Access Chapter).
Age patterns at initiation
Age shaped access use at the time of hemodialysis initiation. The data do not show a single linear trend across ages, which is part of what makes vascular access statistics worth reading carefully.
- In 2016, patients age 0-21 had 7.1% AV fistula use at hemodialysis initiation and 82.2% catheter-only use (2018 USRDS Vascular Access Chapter).
- In 2016, patients age 22-44 had 13.4% AV fistula use at initiation (2018 USRDS Vascular Access Chapter).
- In 2016, patients age 45-64 had 61.4% catheter-only use at initiation (2018 USRDS Vascular Access Chapter).
- In 2016, patients age 65-74 had 18.0% AV fistula use at initiation (2018 USRDS Vascular Access Chapter).
- In 2016, patients age 75+ had 63.7% catheter-only use at initiation (2018 USRDS Vascular Access Chapter).
The youngest group stands out for extremely high catheter-only use. At 82.2%, catheter-only starts among patients age 0-21 were far above the AV fistula share in the same age band (2018 USRDS Vascular Access Chapter). That is not a small difference; it suggests that access planning for younger patients can be very different from adult initiation patterns.
The older age bands also show a strong catheter presence, but not in a uniform way. For example, the 45-64 group had 61.4% catheter-only use, while the 75+ group had 63.7% catheter-only use (2018 USRDS Vascular Access Chapter). That suggests catheter reliance remains substantial across adulthood and later life, even though the exact balance of access types varies by age group.
Sex and race patterns
The access data also show differences by sex and race. These should be read as descriptive patterns from the dataset, not as standalone explanations. They mark where the mix differs; they do not by themselves explain why.
| Group | Notable access pattern at initiation or prevalence | Source |
|---|---|---|
| Male incident patients | 18.3% AV fistula use at initiation | 2018 USRDS Vascular Access Chapter |
| Female incident patients | 4.0% AV graft use at initiation | 2018 USRDS Vascular Access Chapter |
| White incident patients | 17.3% AV fistula use at initiation | 2018 USRDS Vascular Access Chapter |
| Black/African American incident patients | 4.5% AV graft use at initiation | 2018 USRDS Vascular Access Chapter |
| Asian incident patients | 19.8% AV fistula use at initiation | 2018 USRDS Vascular Access Chapter |
| Hispanic incident patients | 66.1% catheter-only use at initiation | 2018 USRDS Vascular Access Chapter |
The contrast between groups is the point. Some groups show relatively higher fistula use at initiation, while others show higher graft or catheter-only use (2018 USRDS Vascular Access Chapter). The Hispanic incident group, for example, had 66.1% catheter-only use at initiation, which places catheter dependence in a clearly dominant position for that subgroup in this dataset (2018 USRDS Vascular Access Chapter).
A few guardrails matter when interpreting these figures:
- the statistics are descriptive, not causal.
- a single percentage does not show timing, referral history, or surgical candidacy.
- the same patient can move from catheter dependence to permanent access over time, which is why initiation and prevalence tell different stories (2018 USRDS Vascular Access Chapter).
Cause of ESRD and vascular access
The underlying cause of kidney failure also aligned with different access patterns. That makes access statistics useful not only for nephrology audiences, but also for anyone trying to understand how disease pathway and treatment access interact.
- In 2016, patients with cystic kidney disease had 38.0% AV fistula use at initiation (2018 USRDS Vascular Access Chapter).
- In 2016, patients with other cause ESRD had 77.7% catheter-only use at initiation (2018 USRDS Vascular Access Chapter).
- In 2016, patients with congestive heart failure had 66.4% catheter-only use at initiation (2018 USRDS Vascular Access Chapter).
- In 2016, patients with peripheral vascular disease had 18.1% catheter with maturing fistula use at initiation (2018 USRDS Vascular Access Chapter).
These rows show that vascular access was not distributed evenly across disease categories. Cystic kidney disease had a notably higher fistula share at initiation than the other listed causes (2018 USRDS Vascular Access Chapter). Meanwhile, other cause ESRD and congestive heart failure were linked with high catheter-only shares, suggesting that the start of treatment in these groups more often depended on a catheter bridge rather than a fully usable permanent access (2018 USRDS Vascular Access Chapter).
Peripheral vascular disease is especially relevant because it appears in a bridge category rather than a pure permanent-access category. The 18.1% catheter with maturing fistula use figure indicates that access planning often had to balance short-term dialysis needs with the longer maturation timeline of a fistula (2018 USRDS Vascular Access Chapter).
What prevalent hemodialysis access looked like in May 2017
Prevalent hemodialysis access in May 2017 was more favorable to permanent access than the incident start data. That difference is important because it shows the effect of time, access maturation, and patient survival on the access mix.
| May 2017 prevalent hemodialysis access | Share | Source |
|---|---|---|
| AV fistula | 64.5% | 2018 USRDS Vascular Access Chapter |
| AV graft | 16.6% | 2018 USRDS Vascular Access Chapter |
| Catheter | 18.9% | 2018 USRDS Vascular Access Chapter |
The prevalence picture is more access-rich than the initiation picture. Fistulas dominate, catheters are much less common than they were at dialysis start, and grafts occupy a meaningful middle position (2018 USRDS Vascular Access Chapter). That is the core difference between incident and prevalent access statistics. One measures the messy transition into dialysis, while the other reflects the access environment after patients have already been in treatment long enough for access patterns to settle.
Several subgroup values sharpen that point:
- By May 2017, patients age 0-21 had 44.0% AV fistula use and 49.3% catheter use (2018 USRDS Vascular Access Chapter).
- By May 2017, patients age 22-44 had 66.2% AV fistula use (2018 USRDS Vascular Access Chapter).
- By May 2017, patients age 45-64 had 66.6% AV fistula use (2018 USRDS Vascular Access Chapter).
- By May 2017, patients age 65-74 had 17.4% AV graft use (2018 USRDS Vascular Access Chapter).
- By May 2017, patients age 75+ had 19.7% catheter use (2018 USRDS Vascular Access Chapter).
The presence of 49.3% catheter use in the youngest prevalent group is striking. It indicates that even among patients already in the prevalent hemodialysis population, catheter dependence could remain substantial in some age groups (2018 USRDS Vascular Access Chapter). At the same time, the 66.2% and 66.6% AV fistula shares in the 22-44 and 45-64 groups show that fistula use becomes much more established in other adult age bands (2018 USRDS Vascular Access Chapter).
How the 2005 to 2017 trend changed
The long-run trend shows gradual progress, not a sudden break. That makes the direction of change clear even if the pace looks modest.
- From 2005 to 2017, AV fistula use at hemodialysis initiation rose from 12.3% to 16.8% (2019 USRDS Executive Summary).
- From 2005 to 2017, patients with either an AV fistula or a maturing AV fistula at hemodialysis initiation increased from 28.9% to 32.0% (2019 USRDS Executive Summary).
- From 2005 to 2017, AV graft use at hemodialysis initiation decreased from 5% to 3% (2019 USRDS Executive Summary).
- In 2017, 80.1% of patients were using a catheter at hemodialysis initiation (2019 USRDS Executive Summary).
The trend line says two things at once. First, fistula use at initiation improved over the period. Second, catheter initiation remained very common in 2017, which shows how persistent the start-of-dialysis access problem remained (2019 USRDS Executive Summary).
That persistence matters because it keeps the clinical and operational burden focused on early access planning. Even with a better fistula share than in 2005, the 2017 picture still had four out of five patients starting on a catheter (2019 USRDS Executive Summary). That is the clearest sign that the system was improving without yet being transformed.
Practical interpretation of the access mix
The statistics support a few practical takeaways.
- Start-of-dialysis access is the most fragile part of the access timeline. The 2016 incident data show that catheter-only starts were still the dominant pattern (2018 USRDS Vascular Access Chapter).
- Prevalent access looks better because time helps permanent access emerge. By May 2017, fistulas were the main access type among prevalent hemodialysis patients (2018 USRDS Vascular Access Chapter).
- The bridge categories matter. Catheter with a maturing fistula or graft captures patients moving toward permanent access, not just patients stuck in catheter-only care (2018 USRDS Vascular Access Chapter).
- Age, subgroup, and cause of ESRD all matter. The access mix was not evenly distributed across the population, which means aggregate statistics can hide important local variation (2018 USRDS Vascular Access Chapter).
The maturation timeline also explains why the access pathway is so difficult. Autogenous AV fistulas require 3 to 6 months to mature, while standard AV grafts can be used after 2 to 4 weeks and early-cannulation grafts within 24 to 72 hours (JAMA 2024 review). That gap in usability timing helps explain why catheter starts remain common when dialysis begins before a permanent access is ready (JAMA 2024 review).
The failure and complication numbers are equally important. Maturation failure occurs in 33% to 62% of AV accesses at 6 months and poor patency in 60% to 63% at 2 years, while access-related steal syndrome affects 1% to 8% of patients (JAMA 2024 review). Those ranges show that access planning is not just about choosing the right access type. It is also about managing uncertainty, timing, and the possibility that a planned access will not function as intended.
Access planning terms to know
A few terms make these statistics easier to read.
- AV fistula: a surgical connection between an artery and a vein used for hemodialysis access (2018 USRDS Vascular Access Chapter).
- AV graft: a synthetic conduit used to connect blood vessels for dialysis access (2018 USRDS Vascular Access Chapter).
- Catheter only: dialysis starts through a catheter without another usable permanent access in place (2018 USRDS Vascular Access Chapter).
- Catheter with a maturing fistula or graft: a temporary catheter is used while a permanent access develops (2018 USRDS Vascular Access Chapter).
- Incident patients: patients starting hemodialysis in the time window being measured (2018 USRDS Vascular Access Chapter).
- Prevalent patients: patients already on hemodialysis at the time of measurement (2018 USRDS Vascular Access Chapter).
The key distinction is that initiation statistics and prevalence statistics answer different questions. Initiation tells you how patients first enter hemodialysis access care. Prevalence tells you how access looks after patients have been in treatment long enough for access selection, maturation, and survival to matter (2018 USRDS Vascular Access Chapter).
For anyone comparing vascular access statistics across studies, that distinction is essential. A high catheter-only start rate does not necessarily mean a high catheter prevalence later. A modest fistula initiation rate can still coexist with strong prevalent fistula use if access maturation and maintenance go well over time (2018 USRDS Vascular Access Chapter).